Hospitalisation for lower respiratory viral infections in older people in residential aged care facilities

COVID-19 outbreak management in Western Sydney residential aged care homes: A mixed-methods Donabedian evaluation

Outbreaks of the novel respiratory viral disease, SARS-CoV-2 (COVID-19), have caused disproportionate morbidity and mortality for older people living in residential aged care homes. Between June 2021 and December 2022, the Delta and Omicron variants of COVID-19 were responsible for widespread outbreaks in homes across Western Sydney, New South Wales, Australia. To manage outbreaks in affected homes, a targeted response strategy was prepared and deployed in the form of outbreak management teams. This study utilised the Donabedian framework and a two-phase mixed methods design to evaluate the structures, processes and outcomes of the outbreak management teams at the level of the local health district. Phase 1 involved the descriptive analysis of outbreak data from Western Sydney aged care homes, created between June 2021 and December 2022. Phase 2 involved the completion of in-depth semi-structured interviews with 35 participants to explore the outbreak management team response from the perspective of its members and staff from residential aged care homes. Between June 2021 and December 2022, there were 281 outbreaks, 4113 resident cases, 346 hospitalisations and 127 deaths in residential aged care homes across Western Sydney. Structural factors that facilitated the outbreak management response and improved outcomes included smaller home sizes, the absence of shared rooms and bathrooms, adequate staffing and resources, suitable infrastructure, and the integration of the response with wider public health systems. Process facilitators included multi-disciplinary team membership, open communication channels, structured and streamlined procedures and roles, onsite infection control support and education, and long-term capability building. The lessons drawn from participants' experiences aim to improve the outcomes and sustainability of current and future outbreak management strategies.

A systematic review of reasons and risks for acute service use by older adult residents of long-term care

AIMS AND OBJECTIVES

To identify the reasons and/or risk factors for hospital admission and/or emergency department attendance for older (≥60 years) residents of long-term care facilities.

BACKGROUND

Older adults' use of acute services is associated with significant financial and social costs. A global understanding of the reasons for the use of acute services may allow for early identification and intervention, avoid clinical deterioration, reduce the demand for health services and improve quality of life.

DESIGN

Systematic review registered in PROSPERO (CRD42022326964) and reported following PRISMA guidelines.

METHODS

The search strategy was developed in consultation with an academic librarian. The strategy used MeSH terms and relevant keywords. Articles published since 2017 in English were eligible for inclusion. CINAHL, MEDLINE, Scopus and Web of Science Core Collection were searched (11/08/22). Title, abstract, and full texts were screened against the inclusion/exclusion criteria; data extraction was performed two blinded reviewers. Quality of evidence was assessed using the NewCastle Ottawa Scale (NOS).

RESULTS

Thirty-nine articles were eligible and included in this review; included research was assessed as high-quality with a low risk of bias. Hospital admission was reported as most likely to occur during the first year of residence in long-term care. Respiratory and cardiovascular diagnoses were frequently associated with acute services use. Frailty, hypotensive medications, falls and inadequate nutrition were associated with unplanned service use.

CONCLUSIONS

Modifiable risks have been identified that may act as a trigger for assessment and be amenable to early intervention. Coordinated intervention may have significant individual, social and economic benefits.

RELEVANCE TO CLINICAL PRACTICE

This review has identified several modifiable reasons for acute service use by older adults. Early and coordinated intervention may reduce the risk of hospital admission and/or emergency department.

REPORTING METHOD

This systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Air Purifiers and Acute Respiratory Infections in Residential Aged Care: A Randomized Clinical Trial

Importance

The effectiveness of in-room air purification for the reduction of acute respiratory infections (ARIs) in residential aged-care facilities (RACFs) is unknown.

Objective

To investigate the effectiveness of in-room air purifiers with high-efficiency particulate air (HEPA)-14 filters in reducing the incidence of ARIs among residents of RACFs.

Design, Setting, and Participants

This randomized clinical trial used a multicenter, double-blind, 2-period, 2-treatment crossover design for 6 months from April 7 to October 26, 2023, in 3 RACFs with a bed capacity of 50 to 100 in New South Wales, Australia. The purposive sampling approach included permanent residents in private rooms in the enrolled RACFs. Data collection was performed every 2 weeks and required no additional follow-up beyond the final data collection on October 31, 2023.

Intervention

An air purifier containing a HEPA-14 filter was placed in rooms of participants in the intervention group, and an air purifier without a HEPA-14 filter was placed in rooms of the control participants. The groups crossed over after 3 months.

Main Outcomes and Measures

The primary outcome was the incidence of ARIs, assessed with logistic mixed-model regression.

Results

Among 135 participants randomized (70 to the intervention-first group and 65 to the control-first group), 78 (57.8%) were female; mean (SD) age was 85.2 (8.6) years. In the intention-to-treat analysis, the use of air purifiers with HEPA-14 filters did not reduce ARIs compared with the control (OR, 0.57; 95% CI, 0.32-1.04; P = .07). Among the 104 participants who completed the entire study, the intervention reduced ARI incidence from 35.6% (37 participants) in the control group to 24.0% (25 participants) in the intervention group (OR, 0.53; 95% CI, 0.28-1.00; P = .048).

Conclusions and Relevance

In this clinical trial investigating use of air purifiers with HEPA-14 filters for reducing ARIs, no significant between-group difference was found in the intention-to-treat analysis. However, a significant reduction in ARIs was identified among participants who completed the entire study. These findings may help inform future large-scale studies of respiratory infectious diseases.

Trial Registration

ANZCTR identification: ACTRN12623000347662.

The Utilization and National Variation of Plain X-Ray Services by Australian Residents of Long-Term Care Facilities

OBJECTIVES

To (1) estimate incidence, trends, and determinants of government-subsidized diagnostic radiography (ie, plain x-ray) services utilization by Australian long-term care facility (LTCF) residents between 2009 and 2016; (2) examine national variation in services use.

DESIGN

A repeated cross-sectional study.

SETTING AND PARTICIPANTS

Australian LTCF residents who were ≥65 years old.

METHODS

Medicare Benefits Schedule subsidized plain x-rays employed for diagnosing fall-related injuries, pneumonia, heart failure, and acute abdomen or bowel obstruction were identified. Yearly sex- and age-standardized utilization rates were calculated. Poisson and negative binomial regression models were employed. Facility-level variation was examined graphically. Overall and examination site-specific analyses were conducted.

RESULTS

A total of 521,497 LTCF episodes for 453,996 individuals living in 3018 LTCFs were examined. The median age was 84 years (interquartile range 79-88), 65% (n = 339,116) were women, and 53.9% (n = 281,297) had dementia. In addition, 34.5% (n = 341,6863) of episodes had at least 1 x-ray service. Overall, there was a 12% increase in utilization between 2009 and 2016 (from 535/1000 in 2009 to 602/1000 person-years in 2016, incidence rate ratio=1.02, 95% CI 1.02-1.02). Factors associated with x-ray use included being 80-89 years old, being a man, not having dementia, having multiple health conditions (4-6 or ≥7 compared to 0-3), being at a smaller facility (0-24 bed compared to 50-74), facility located in the Australian state of New South Wales, or in major cities (compared to regional areas). National variation in x-ray service use, with largest differences observed by state, was detected.

CONCLUSIONS AND IMPLICATIONS

Plain x-ray service utilization by LTCF residents increased 12% between 2009 and 2016. Sex, age, dementia status, having multiple health conditions as well as facility size, and location were associated with plain x-ray use in LTCFs and use varied geographically. Differences in x-ray service utilization by residents highlight lack of consistent access and potential over- or underutilization.